The Putney Prolonged Disorders of Consciousness Toolkit Holy Cross... · The Putney Prolonged...

The Putney Prolonged Disorders of Consciousness Toolkit

A set of practical resources to support the assessment and monitoring of patients in a Prolonged Disorder of

Consciousness

Susie Wilford, Amy PundoleDr Sarah Crawford, Dr Andrew Hanrahan

• Rationale• The Putney PDOC Toolkit

o 24 hour managemento Behavioural observations o Emotional responseso Interactionso Functional object useo Command followingo Swallowingo Individual assessment planso Emergenceo Monitoring

Contents

RationaleInformal assessment

Toolkit is a set of resources to support assessment and monitoring

Set of non-standardised assessmentsAims to support patient-centred assessment in a more flexible waySupports clinicians to clinically evaluate behaviours in areas of uncertainty

RationaleInformal assessmentSupports the formal assessment process

Enables clinicians to collect evidence, in a meaningful environment, on behaviours to:

• Support diagnosis• Support family/carer education• Identify and signpost the highest level of

response that can be further explored

How do we build a picture of a patient in a PDOC?

WHIM ?SMART ?CRS-R ?OTHER ?

MAIN THEMES

WHICH ASSESSMENT

TOOL?

OUTCOMESNo one

assessment tool is perfect

Combine 2 or more tools

Patient characteristics

Assessment characteristics

Pragmatics

WHIM ?SMART ?CRS-R ?OTHER ?

Pragmatics

Assessment characteristics

WHIM ?SMART ?CRS-R ?OTHER ?

Pragmatics

WHICH ASSESSMENT

TOOL?

No one assessment

tool is perfect

Combine 2 or more tools

Patient characteristics

Assessment characteristics

WHIM ?SMART ?CRS-R ?OTHER ?

Pragmatics

• Recording and fostering regular sleep-wake patterns

• Creating an environment with light and dark periods

• Consider the environment in all contexts

• How to ensure the individual is best supported to be able to demonstrate what they are able to do

24 hour management

• Weekly planner

• ‘Help me get a good rest’ guidelines

• Arousal monitoring

• Arousal chart (24 hours)

24 hour management

Behavioural Observations

• Need to understand what the patient is doing at rest when no stimuli have been applied

Behavioural Observations

Eye Movement Observations• Tally of number of blinks• Direction of the eyes• Observations

Tally Charts

Tally Charts

Emotional Responses• Range of behaviours that are usually linked with 

emotions, such as tears, grimacing, smiling• Difficult to score on formal tools • Individualised approach that avoids words such as 

‘depression’ and ‘pain’ and focuses instead on behaviours. 

• Use a flow chart when team raise concerns about low mood

• Measure behaviours before, during and after treatment (antidepressants/neurostimulants/behavioural activation)

Emotional Responses

Interactions

• Lack reliable communication• We set up the environment to promote appropriate interaction/communication wherever possible

• Chat Mat – what to talk about• Communication passport – how to talk to me• ‘Help me fill my free time’‐ appropriate leisure activities and how to monitor

Chat Mat

[ Insert photo of patient here ]

Communication Passport

Functional Objects

• Emergence criteria• Functional assessment with everyday familiar objects

• Record which objects trialled, how they are held and manipulated

• Do they use the object appropriately

Using objects

Following Commands

• Used to distinguish VS/MCS• Need individual approach• ‘Top tips’• Pick right command• Compare to movements at rest• Try rewording or modelling

Swallowing

• The 2013 RCP PDOC guidelines consider oral feeding a form of sensory stimulation

• Intentional behaviours such as anticipatory mouth opening or licking residue from lips

• Additional information on interaction, communication and awareness by providing a functional context in which to communicate likes/dislike/choices/’more’

• Little research in this area• Practical ideas for SLTs• What to look for in PDOC swallow assessment• Guidance on clinical reasoning and  best interests decision making 

Swallowing

Individual Assessment Plans

Emergence

• Based on suggestions from RCP guidelines• Yes/no and discrimination tasks using

autobiographical information, everyday objects and colours

• Items visually, semantically and phonologically distinct

Monitoring

Annual Reviews

• 6 week programme

• Looks at behaviours

• Seen in either a group setting and/or 1:1

• Minimum of 4 sessions

• WHIM completed with all patients

• CRS-R if used previously

• Summary report

Week Programme outline

Prior to week one • Screening form completed by MDT

Week one • Staff planning• Information given to 

family• First group

Weeks 2 – 4 • Groups 2 – 4• Individual sessions 

Weeks 5‐6 • Results collated• Summary report• Actions identified and an 

action plan put in place

Monitoring

Annual Reviews – Groups

• Activities can be varied based on the patient’s interests/preferences

• Provides an opportunity for patients to respond to a range of sensory stimuli within a meaningful and familiar activity

• Patients supported to look at, hear, touch and smell

Sensory Art Group• Using items from the garden 

such as herbs/ leaves, • Using clay and paint

Sensory Baking Group• Making a variety of sweet 

and savoury treats based on previous preferences

Any questions? Ideas?

Contact details

Susie WilfordSenior I Occupational Therapistswilford@rhn.org.uk

Amy PundoleClinical Lead Speech and Language Therapistapundole@rhn.org.uk

Dr Sarah CrawfordConsultant Clinical Neuropsychologist & Professional Lead for Clinical Psychologyscrawford@rhn.org.uk

Dr Andrew HanrahanConsultant in Neuro-rehabilitation; Lead Consultant Brain Injury Serviceahanrahan@rhn.org.uk